Dental use and expenditures for older uninsured Americans: the simulated impact of expanded coverage

OBJECTIVE

To determine if providing dental insurance to older Americans would close the current gaps in dental use and expenditure between insured and uninsured older Americans.

DATA SOURCES/STUDY SETTING

We used data from the 2008 Health and Retirement Survey (HRS) supplemented by data from the 2006 Medical Expenditure Panel Survey (MEPS).

STUDY DESIGN

We compared the simulated dental use and expenditures rates of newly insured persons against the corresponding rates for those previously insured.

DATA COLLECTION/EXTRACTION METHODS

The HRS is a nationally representative survey administered by the Institute for Social Research (ISR). The MEPS is a nationally representative household survey sponsored by the Agency for Healthcare Research and Quality (AHRQ).

PRINCIPAL FINDINGS

We found that expanding dental coverage to older uninsured Americans would close previous gaps in dental use and expense between uninsured and insured noninstitutionalized Americans 55 years and older.

CONCLUSIONS

Providing dental coverage to previously uninsured older adults would produce estimated monthly costs net of markups for administrative costs that comport closely to current market rates. Estimates also suggest that the total cost of providing dental coverage targeted specifically to nonusers of dental care may be less than similar costs for prior users.

Patterns of older Americans' health care utilization over time

OBJECTIVES

We analyzed correlates of older Americans' continuous and transitional health care utilization over 4 years.

METHODS

We analyzed data for civilian, noninstitutionalized US individuals older than 50 years from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of persistent and intermittent use of physician, inpatient hospital, home health, and outpatient surgery over the 2004-2008 survey periods.

RESULTS

Individuals with worse or worsening health were more likely to persistently use medical care and transition into care and not transition out of care over time. Financial variables were less often significant and, when significant, were often in an unexpected direction.

CONCLUSIONS

Older individuals' health and changes in health are more strongly correlated with persistence of and changes in care-seeking behavior over time than are financial status and changes in financial status. The more pronounced sensitivity to health status and changes in health are important considerations in insurance and retirement policy reforms.

Dental usage under changing economic conditions

OBJECTIVE

The purpose of this article is to examine the relationship between changes in household finances (wealth and income) and changes in dental utilization at the onset of the recent recession in a population of older Americans.

METHODS

Data from the Health and Retirement Study (HRS) were analyzed for U.S. individuals aged 51 years and older during the 2006 and 2008 waves of the HRS. We estimated logistic models of (a) starting and (b) stopping dental use between 2006 and 2008 survey periods as a function of changes in household wealth and income, controlling for other potentially confounding covariates.

RESULTS

We found that only when household wealth falls by 50 percent or more were older adults less likely to seek dental care. Changes in household income and other changes in household wealth were not associated with changes in dental utilization among this population.

CONCLUSIONS

Older Americans' dental care utilization appeared to be fairly resilient to changes in household finances; only when wealth fell by 50 percent or more did individuals decrease dental use. This finding might extend to other health-care services that are preventive, routine, and relatively inexpensive.

The Financial Repercussions of New Work-Limiting Health Conditions for Older Workers

This analysis used propensity score matching to construct a comparison sample that is observationally similar at baseline interview to older workers who later experience the onset of a medical condition that limits their ability to work. Using these matched onset and comparison samples, we studied trajectories in earnings and income around onset of the work limitation. Earnings two years after onset for the work-limitation group were 50% lower and poverty rates were nearly double. Income from unemployment insurance, workers' compensation, and retirement and disability benefits offset only a small amount of the earnings declines, resulting in decreased overall household income after onset of the work-limiting condition.

Wealth effect and dental care utilization in the United States

OBJECTIVE

The purpose of this article is to examine the relationship of wealth and income and the relative impact of each on dental utilization in a population of older Americans, using data from the Health and Retirement Study (HRS).

METHODS

Data from the HRS were analyzed for US individuals aged 51 years and older during the 2008 wave of the HRS. The primary focus of the analysis is the relationship between wealth, income, and dental utilization. We estimate a multivariable model of dental use controlling for wealth, income, and other potentially confounding covariates.

RESULTS

We find that both wealth and income each have a strong and independent positive effect on dental care use of older Americans (P < 0.05). A test of the interaction between income and wealth in our model failed to show that the impact on dental care utilization as wealth increases depends on a person's income level or, alternatively, that the impact on dental use as income increases depends on a person's household wealth status (P > 0.05).

CONCLUSIONS

Relative to those living in the wealthiest US households, the likelihood of utilizing dental care appears to decrease with a decline in wealth. The likelihood of utilizing dental care also appears to decrease with a decline in income as well.

The influence of changes in dental care coverage on dental care utilization among retirees and near-retirees in the United States, 2004-2006

OBJECTIVES

We examined dental care utilization transition dynamics between 2004 and 2006 in the context of changing dental coverage status.

METHODS

We used data from the Health and Retirement Study for persons aged 51 years and older to estimate a multivariable model of dental care use transitions with controls for dental coverage and retirement transitions and other potentially confounding covariates.

RESULTS

We found that Americans aged 51 years and older who lost dental coverage between the 2004 and 2006 survey periods were more likely to stop dental care use between periods, and those who gained coverage were more likely to start dental care use between periods, than those without coverage in both periods.

CONCLUSIONS

Dental coverage transitions and status have a strong effect on transitions in dental care use. Given that retirement is a time when many experience a loss of dental coverage, older adults may be at risk for sporadic dental care and even stopping use, leading to worse dental and potentially overall health.

Disability benefits suspended or terminated because of work

We use a new variable in the Social Security Administration's Ticket Research File to produce statistics on the first month of suspension or termination for work (STW) for Social Security Disability Insurance (DI) and Supplemental Security Income (SSI)-only beneficiaries as well as on the number of months in nonpayment status following suspension or termination for work (NSTW) before their return to the rolls, attainment of the full retirement age, or death--in each year from 2002 through 2006. Less than 1 percent of beneficiaries experienced their first STW in each year, but more were in NSTW in at least 1 month. Ticket to Work (TTW) participants were more likely to have a first STW than nonparticipants, but most of those who had an STW were not TTW participants, reflecting low use of TTW. Employment networks often failed to file claims for outcome payments during months when their TTW clients were in NSTW.

How common is "parking" among Social Security Disability Insurance beneficiaries? Evidence from the 1999 change in the earnings level of substantial gainful activity

Fewer Social Security Disability Insurance (DI) beneficiaries have their earnings suspended or terminated because of work than those who are actually working, partly because beneficiaries "park" earnings at a level below substantial gainful activity (SGA) to retain benefits. We assess the extent of parking by exploiting the 1999 change in the SGA earnings level from $500 to $700 monthly for nonblind beneficiaries using a difference-indifference analysis that compares two annual cohorts of beneficiaries who completed their trial work period, one that was affected by the SGA change and one that was not. Our impact estimates, along with results from other sources, suggest that from 0.2 to 0.4 percent of all DI beneficiaries were parked below the SGA level in the typical month from 2002 through 2006. The SGA change did not yield any difference in mean earnings, although it did result in a small reduction in months spent off of the rolls because of work.

Dental care expenditures and retirement

OBJECTIVES

To examine the relationship of dental care coverage, retirement, and out-of-pocket (OOP) dental expenditures in an aging population, using data from the Health and Retirement Study (HRS).

METHODS

We estimate OOP dental expenditures among individuals who have dental utilization as a function of dental care coverage status, retirement, and individual and household characteristics. We also estimate a multivariate model controlling for potentially confounding variables.

RESULTS

Overall, mean OOP dental expenditures among those with any spending were substantially larger for those without coverage than for those with coverage. However, controlling for coverage shows that there is little difference in spending by retirement status.

CONCLUSIONS

Although having dental coverage is a key determinant of the level of OOP expenditures on dental care; spending is higher among those without coverage than those who have dental insurance. We also found that while retirement has no independent effect on OOP dental expenditures once controlling for coverage, dental coverage rates are much lower among retirees.

Dental care utilization and retirement

OBJECTIVE

The authors examine the relationship of dental care coverage, retirement, and utilization in an aging population using data from the Health and Retirement Study (HRS).

METHODS

The authors estimate dental care use as a function of dental care coverage status, retirement, and individual and household characteristics. They also estimate a multivariate model controlling for potentially confounding variables.

RESULTS

The authors show that that the loss of income and dental coverage associated with retirement may lead to lower use rates but this effect may be offset by other unobserved aspects of retirement including more available free time leading to an overall higher use rate.

CONCLUSIONS

The authors conclude from this study that full retirement accompanied by reduced income and dental insurance coverage produces lower utilization of dental services. However, they also show that retirement acts as an independent variable, whereas income, coverage, and free time (unobserved) act as intervening variables.

Dental care coverage and retirement

OBJECTIVES

To examine the convergence of an aging population and a decreased availability of dental care coverage using data from the Health and Retirement Study (HRS).

METHODS

We calculate national estimates of the number and characteristics of those persons age 51 years and above covered by dental insurance by labor force, retirement status, and source of coverage. We also estimate a multivariate model controlling for potentially confounding variables.

RESULTS

We show that being in the labor force is a strong predictor of having dental coverage. For older retired adults not in the labor force, the only source for dental coverage is either a postretirement health benefit or spousal coverage.

CONCLUSIONS

Dental care, generally not covered in Medicare, is an important factor in the decision to seek dental care. It is important to understand the relationship between retirement and dental coverage in order to identify the best ways of improving oral health and access to care among older Americans.

Dental care coverage transitions

OBJECTIVE

To examine dental insurance transition dynamics in the context of changing employment and retirement status.

STUDY DESIGN

Data from the Health and Retirement Study (HRS) were analyzed for individuals 51 years and older between the 2004 and 2006 waves of the HRS.

METHODS

The primary focus of the analysis is the relationship between retirement and transitions in dental care coverage. We calculate and present bivariate relationships between dental coverage and retirement status transitions over time and estimate a multivariable model of dental coverage controlling for retirement and other potentially confounding covariates.

RESULTS

Older adults are likely to lose their dental coverage on entering retirement compared with those who remain in the labor force between waves of the HRS. While more than half of those persons in the youngest group (51-64 years) were covered over this entire period, two-thirds of those in the oldest group (>or=75 years) were without coverage over the same period. We observe a high percentage of older persons flowing into and out of dental coverage over the period of our study, similar to flows into and out of poverty.

CONCLUSIONS

Dental insurance is an important factor in the decision to seek dental care. Yet, no dental coverage is provided by Medicare, which provides medical insurance for almost all Americans 65 years and older. This loss of coverage could lead to distortions in the timing of when to seek care, ultimately leading to worse oral and overall health.

Raising the graduation bar for the schools: expectations vs outcomes

Educational reform is an ongoing concern of parents, educators, policy makers, and the public at large. The past 50 years have ushered in a new era of reform, whose major objective was to improve students' performance based on the use of statewide standardized testing and changes in graduation requirements. This study examined one such reform movement, initially developed during the late 1970s, which developed minimum competency testing standards as well as increased course demands to specify graduation requirements for public high school students. The outcomes for this reform model, both in terms of students' achievement and failure, did not meet expectations.

Tween consumers: catalog clothing purchase behavior

The purpose of this study was to compare the catalog shopping behavior of students in their tween years (i.e., between childhood and adolescence; ages 12-14) with that of older students (ages 15-18). Junior high and high school students who had purchased clothing from a catalog in the past 12 months responded to a questionnaire that examined the label information sought and product-specific attributes considered. Results indicated that tweens were more concerned with style, brand names, and the latest fashion than were older students. This finding was especially interesting, as these attributes all relate to status; the tweens were more interested than the older students in wearing the latest fashions, being in style, and gaining the prestige of wearing brand-name clothing. This supports previous findings indicating that the tween years are a time when peer pressure and "fitting in" are very important.